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AYHA 2008 - 09

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ADRIAN YOUTH HOCKEY ASSOCIATION

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PO Box 297 Adrian, Michigan, 49221

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PLAYER REGISTRATION FORM RETURN BY SEPTEMBER 13, 2008 FOR PRIORITY CONSIDERATION

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PLEASE PRINT & COMPLETE ALL OF THE FOLLOWING INFORMATION:

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LevelBirth YearProgram FeeLevelBirth YearProgram FeeRegistration Fee: $150

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Mini Mite 2002-03$475Bantam1994-95 $775$150 due with registration. Payment

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Mite 2000-01$495Midget B1992-93$850plans will be available for program

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Squirt 1998-99$625Midget BB1990-91$950fees. Registration fee will be deducted from Program fee.

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Pee Wee 1996-97$675

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Inst. 1 & 2Ages 5-15$225(2 payments of $112.50. 1st payment due with registration)

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Player's Name:___________________________________________________Player's Jersey Size:youth adultS M L XL

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firstmiddle initiallastmale______

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Home Address:___________________________________________________Player's Date of Birth: _____________female_____

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City:_______________________________Zip:_________School District:________________________________Grade: ________

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Home Phone:_________________________ Name of School:_________________________________Not decided

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Father:______________________Organization player skated in Fall 2007-08:

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Employer:______________________Phone: ______________AYHAOther: _______________________

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Mother:______________________Player's Hockey Experience:None

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Employer:______________________Phone:______________HouseTravelLTPGirls

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Email address:___________________________OffenseDefenseGoalie

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________please contact me to sponsor a teamParent's Prior Hockey Experience (check all that apply)

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________please contact me for fundraising committeeHigh SchoolCollegeCoaching

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________I am willing to help with other AYHA committee's / activitiesI am interested in coaching a team Yes No

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Initial lines (1) through (11) : TERMS & CONDITIONS

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1As a parent or legal guardian, I give permission for my child to participate in the AYHA program.

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2I agree to pay all fees when due (either in Full, at or prior to the evaluation skate, or per attached Automatic Payment

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Authorization Form) and understand that failure to pay will result in the suspension of my child's playing privileges.

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3Player is responsible for all required equipment; including mouth guard, neck guard, supporter and cup, shoulder pads, USA hockey

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approved helmet and face guard, elbow pads, shin guards, pants, stick and skates.

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4I understand that my conduct and the conduct of my child is governed by the Rules & Regulations of AYHA, MAHA, USA Hockey,

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and the Ice Arena played in, and that any violation of these rules may subject me or my child to removal from the AYHA program

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without refund and/or removal from the Ice Arena.

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5I will read and abide by the MAHA S.T.A.R. guidelines throughout the season.

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6I am responsible for any AYHA equipment issued to my child and will return the equipment in good condition and agree to reimburse

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AYHA for any lost or damaged equipment.

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7I certify that the birth date of my child given above is correct, that I am required to supply a valid copy of his/her birth certificate

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every year prior to or at the evaluation skate and that my child is physically capable of playing.

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8I understand that I am required to participate to the best of my abilities in AYHA fundraising activities during the season.

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9I understand and appreciate that the risk of injury from hockey is significant, including the potential for permanent paralysis

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and death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk is serious and injury does exist.

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By my child's participation, I knowingly assume all such risks, both known and unknown. I hereby waive and release any

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claims against the AYHA or AYHA volunteers for any injuries sustained to my child during any AYHA sponsored activity. This is also to certify

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that the AYHA is authorized to obtain whatever medical treatment is required in the event of an injury and that I agree to pay

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all expenses incurred for emergency care. I acknowledge that all registrations are accepted with this understanding.

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10I have read and fully understand ALL the information contained in the AYHA Registration Information Sheet(s).

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11I give permission to the AYHA to use my childs and/or my picture and name in AYHA publications.

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REQUIRED:Parent/Guardian Signature:Date:

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Printed name:check enclosed

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Charge $155 (includes $5.00 fee) to my:VISA / MC # Exp:

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Credit card, check or money order only. Do not send cash.

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